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Anticoagulation and its use in

haemodialysis
Lestariningsih
Subbag Nefrologi / Hipertensi
Bag Penyakit Dalam FK UNDIP/RS Dr Kariadi

Georgina Follows Hdx foundation m


Basic clinical dialysis,
odule

Highlight
contact with plastic tubing, the dialysis membran and air
in the HD circuit stimulates the clothing cascades
excessive clotting in the dialysis circuit and filter need to be
discarded, in adult, this can mean the loss of 120-250 ml of blood
clotting within an HD circuit can be minimised through aprpropiate
use of anticoagulant therapy
periodic anticoagulation is normally given during the dialysis
treatment

Georgina Follows Hdx foundation m


Basic clinical dialysis,
odule

Aims and objectives


To gain understanding of the mechanisms involved in the
clotting process and coagulation assessment.
To gain understanding of heparin, its administration,
advantages and disadvantages.
To gain understanding of any contraindications to heparin
uses.
To gain understanding of any alternatives to heparin usage.

Georgina Follows Hd

Basic clinical dialysis,

Introduction
Blood comes into contact with extrinsic factors during
haemodialysis.
Heparin is the most commonly used anticoagulant during
dialysis.
Administration of heparin
Bolus dose at the beginning of dialysis
Continuous infusion during dialysis.
Both of these methods are prescribed and can be altered to
tailor each patients needs.

Georgina Follows Hd

Basic clinical dialysis,

The Coagulation Cascade


Vascular Constriction
Platelet plug formation

Formation of blood clots

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Normal clotting mechanisms


There are two methods by which the coagulation cascade is
activated:
Intrinsic pathway.
Initiated when blood comes into contact with foreign
surface.
Platelets become damaged and release phospholipids.
Phospholipids join with Factor VIII and Factor IX to form
Factor X. Factor X combines with calcium to form
prothrombin and activates the coagulation cascade.
Georgina Follows Hd

Basic clinical dialysis,

Extrinsic pathway
Damaged tissue thromboplastin released initiates
formation of prothrombinase in presence of Factor X and
calcium ions.
The coagulation cascade then occurs by using thrombin
an enzyme that converts fibrinogen into fibrin. This forms
a mesh trapping the formed elements of blood thus
forming a CLOT.

Georgina Follows Hd

Basic clinical dialysis,

QUESTION???

Which pathway

is initiated during
haemodialysis?

Georgina Follows Hd

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Heparin
Discovered in 1916 by McLean
Anticoagulant found in the liver
Porcine and bovine preparations
Molecular weight = 3000 to 30000 Daltons
Binds to thrombin inhibitor ANTITHROMBIN III >
inactivates active Factor X and inhibits conversion of
prothrombin to thrombin

Georgina Follows Hd

Basic clinical dialysis,

Advantages of Heparin
I.V. direct access
Cheap
Metabolised naturally by the liver
Acts quickly and effectively on the intrinsic pathway
Reversed quickly and easily by Protamine
Long, established history of use

Georgina Follows Hd

Basic clinical dialysis,

Disadvantages of Heparin
Bleeding
Hyperlipidaemia
Thrombocytopenia
Allergic reactions
Pruritis
Alopecia
Osteoporosis

Georgina Follows Hd

Basic clinical dialysis,

Assessment of coagulation
Clotting times APTT (Actual Partial thromboplastin
Time) or ACT (Activated Clotting Time) 120 secs
Observe for signs of clotting
- Darkened blood
- Streaks in dialyser
- Clots / fibrin rings in chambers
- Blood entering venous isolator
- Rising / falling venous pressure

Georgina Follows Hd

Basic clinical dialysis,

Factors affecting coagulation


Blood flow
High haematocrit levels
EPO
Blood transfusion
Intra-dialytic lipid infusion
High UF rate
Type of circuit
Medication
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Basic clinical dialysis,

Factors affecting coagulation cont.


Individual clotting abnormalities
Type of dialyser
Membrane
- Natural membranes e.g. cuprophane relatively
high platelet activation
- Synthetic membranes vary. Polysulphone more
compatible with blood than Cuprophane and
Cellulose

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Basic clinical dialysis,

Contraindications for heparin use


Pericarditis
Pre and post surgery, < 48 hour
Following temporary line insertion
Coagulation abnormalities, therapy antiplatelet
Thrombocytopenia, < 150 X l0 9/L
Intracranial haemorrhage
Any active bleeding
Uraemic patients
Heparin free dialysis : flushing the dialyzer with 100ml Nacl 0,9%
Every 30-60 minute

Georgina Follows Hd

Basic clinical dialysis,

Contraindications for heparin use cont.


Peptic ulcer
Aortic aneurysm
Cerebral aneurysm
Severe liver disease
Hypersensitivity / allergic reactions

Georgina Follows Hd

Basic clinical dialysis,

Standard Heparin (UFH) Dose


bolus dose 2500 U ( 50U/kgBB), maintenance 1000/jam
atau initial HD: loading dose of 250-500 U followed by infusion
rate 250-500, max 2000U
Heparin Free Dialysis
Obtain baseline clotting time
5000u heparin rinse
High blood flow rate
100-200 mls saline flush every 30 mins
Georgina Follows Hd

Basic clinical dialysis,

L.M.W.H. inhibits Factor X, little thrombin inhibition,


APTT / ACT minimally prolonged.

Advantages
Safe, effective & decreased bleeding risk
Simple single dose required
Reduced cholesterol and triglyceride levels
Reduced alopecia
Disadvantages
Expensive, long half life, not use ACTs

Georgina Follows Hd

Basic clinical dialysis,

Future

Coating of elements of
circuit with active
heparin.
Non-thrombogenic
membranes.
Heparinised coated
cartridges capable of
removing heparin
infused into the extra
corporeal circuit.

Georgina Follows Hd

Basic clinical dialysis,

QUESTIONS

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GROUP WORK
A patient complains of loss of hair over the past
couple of months. She has minimal heparin on
dialysis, but still no change, what would you do??

A patient has just completed dialysis and you


notice that the kidney is very dark. The patient is
already on high doses of heparin. What would you
do??
Georgina Follows Hd

Basic clinical dialysis,